A 28-year old Lithuanian woman presented with a 6-week history of firm anterior neck swelling. There were no symptoms of local obstruction, invasion, or thyroid dysfunction, and no past medical history, medication use or relevant family history. On initial assessment, she was euthyroid, with a 6 cm hard mass replacing the right lobe of the thyroid, a 2 cm lymph node lateral to it, but no other lymphadenopathy. No cellular material could be obtained on initial clinical and ultrasound-guided fine-needle aspirates. An ultrasound-guided core biopsy of the thyroid mass revealed a diffuse inflammatory cell infiltrate comprising lymphocytes and eosinophils, no thyroid follicles, and extrathyroidal fibrosis. These appearances were thought to be in keeping with Reidels thyroiditis.
The patient then deteriorated, developing stridor, dysphagia and snoring. Her tracheal diameter fell from 8 to 4 mm over a 6-week period. She was admitted immediately and started on 1 mg/kg oral prednisolone. Within hours of the first dose, her symptoms improved. Her FEV1 rose from 2.54 to 2.8 l over 48 h, accompanied by a clinically appreciable 20% reduction in the size of the mass.
Though the histology was compelling for Reidels thyroiditis, this was not in keeping with the clinical finding of lymphadenopathy. She was also perceived to be at increased risk of papillary thyroid cancer, due to childhood exposure to fallout from the Chernobyl disaster. Lymph node biopsy was therefore performed prior to starting prednisolone therapy. This revealed a mixed lymphoid population and Reed Sternberg cells staining for CD30 and CD15. Subsequent immunohistochemical staining of the thyroid biopsy revealed the same appearances, and the patient is now responding to ABVD chemotherapy.
Intrathyroidal Hodgkins lymphoma is a rare form of a rare disease in 6 series comprising 248 cases of thyroidal lymphoma, only 3 patients had Hodgkins lymphoma and was an unexpected underlying diagnosis in this case.